VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Berryville
413 McClellan Street
Berryville, VA 22611
(540) 955-4557

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Feb. 19, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

1. The previous administrator signed off indicating review of service plans but they were not complete or in some cases the assessments had not been updated so the two would match - this is a priority for the next inspection and was observed to be in progress by the new director of nursing. 2. Provide basic orientation as it relates emergency procedures for outside providers and document accordingly. 3. Add generator information to disclosure - an example can be found on the DSS website. 4. Resident records had paperwork that was incomplete or blank, much of which was Commonwealth required and not standard required. Al;l files need to be reviewed. 5. Resident L - review with hospice justification for the use of medication for nausea prior to pain medication when no record of nausea with use.

Comments:

The facility had two violations identified during this unannounced sixty day monitoring inspection required for new facilities. They were in the area of medication administration, primarily documentation and call log documentation. Details can be found in the violations portion of this report. The facility has a new administrator and director of nursing who started after the initial take over by the new owners. They are experienced with the regulations and are working together and with their team to bring the facility completely into compliance. The facility was clean and odor free. Residents and families voiced no concerns and indicated they were pleased with a lot of the changes that have been made. Outside inspections remain current and will be reviewed again during the renewal inspection. Change of ownership requires a renewal inspection six months after the issuance of a conditional license. The facility is scheduled to have an additional inspection prior to the final renewal. Thank you to residents, families and staff for your cooperation during this inspection process. If you have additional questions or concerns please call (540) 332-2330 or e-mail this inspector at sharon.deboever@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-I
Description:	Based on a review of a random selection of medication administration the following issues were identified related to documentation: Resident I: Injections are being given by the administrator who is a nurse but documented as being given by a medication aide; blood pressure was taken twice a day with no instructions when to report to physician or potentially hold medication; duplicate order for diltiazem noted three of 19 days by staff but the remainder it appears as if both doses were given as per documentation (review of medication indicated not the case); oxygen orders do not contain a source; MAPAP order should indicate how many doses not to exceed as opposed to "3gm". Resident J: Pulse was recorded as "1" on three different occasions; blood pressure being taken prior to use of medication with no parameters for when to contact physician or hold medication; monitor PRN usage documentation for consistency. Resident K: Blood sugar checks did not have actual readings and no parameters regarding insulin and when to notify physician or hold. Resident L: Order for mirtazipine noted as not given on 2/8,10,11,12,14,15,16 and 17 due to not being available and on order from pharmacy but noted as given 2/9 and 2/13; oxygen order needs source there is further no inidcation that physician was made aware medication was not available.
Plan of Correction:	The facility has a new director of nursing who has begun to review all medication orders and their respective MARS. Any changes or corrections including those in the violation will be addressed with physicians or hospice as applicable. Staff will also be receiving additional training regarding reporting and documentation. The director of nursing and administrator assume responsibility for corrections and future compliance.
Standard #:	22VAC40-73-930-D
Description:	Based on a review of the log maintained for those individuals unable to use the call bell system the log was missing initials related to check times that had past. For resident H the service plan indicated that checks would be hourly but the log reflected checks every two hours.
Plan of Correction:	Log use will be reviewed with all staff as applicable. Charge staff will begin monitoring logs randomly to ensure they are being completed in a timely manner which is as check is completed. Service plans will also be reviewed to ensure times match. The administrator and memory care coordinator assume responsibility for corrections and future compliance.